CAROTID ARTERIES, BLOOD-PRESSURE, AND STROKES

208 its general civilisation.

practice is

a

reflection of the

Barton-on-Humber,

quality

of

a

H F. F HOWARD. ’T". H S. S H.

Lincolnshire.

RUPTURE OF THE POSTERIOR URETHRA

SIR,-We have for

taught the following a which includes number of regime, points (indicated by italics) not previously mentioned in this correspondence: many years

(1) Explore, open the bladder and introduce a urethral bougie by guiding it with the tip of the forefinger, passed from within outwards through the prostatic urethra to the retropubic space. This simple manoeuvre obviates the need for juggling with " interlocking sounds ", or (even more tricky) with two ordinary bougies. (2) Railroad a Foley catheter or an improvised traction device. (3) Place a dressing of fluffed gauze over the wound and correct and fix the fracture-dislocation of the pelvis, with orthopzedilc assistance if available. (4) Expose and remove the suprapubic dressing and, with a finger in the bladder, press the prostate firmly downwards onto the triangular ligament. (5) Close the bladder around sump-suction drainage. (6) Apply adequate traction to the urethral catheter. Mr. Wilkinson (May 27) rightly says, " Work in conjunction with the orthopxdist ", but it is left to Mr.

Gissane (July 8) to insist (and I agree) that " the fundamental principles of wound treatment " demand " the early and close approximation of all the components of the wound ". Whether or not he is right in believing that this is best achieved in " highly organised units " seems to me less important than that the one essential surgical principle which he stresses should be well understood. A good system of management can then be firmly based on this principle. Department of Surgery, University of Liverpool.

C WELLS. CHARLES W

ANTI-HISTAMINES AND PROTECTION AGAINST LIVER INJURY

SiR,-Prompted by your annotation1 about the observations by Judah et al.2-5 which suggested that antihistamines inhibited the increased permeability and associated mitochondrial swelling in various forms of hepatic damage in animals, we began a study to determine the effects of an anti-histamine on the course of viral hepatitis in men. Patients with hepatitis were separated into two groups according to their date of admission to the hospital. The antihistamine, chlorpheniramine maleate (’ Chlor-Trimeton ’), was

selected for the treated group because of its relative freedom from side-effects and was given in large doses (64 mg. per day). Patients in the control group received a placebo. The specific members of the groups and the nature of the medication given to each were known only to the medical supervisor of the ward. Each patient was treated in addition with the usual hepatitis regimen of high-calorie, high-protein diet and modified bedrest. Discharge from the hospital was considered feasible when the bromsulphalein (B.s.p.), bilirubin, and serum-glutamicoxalacetic transaminase (S.G.O.T.) remained at acceptable, almost-normal levels for two consecutive weeks. The treated group of 8 patients averaged forty-three days before being fit for discharge, the control group (6 patients) forty-two days. In the treated group there was 1 relapse requiring an additional forty days in hospital and 1 episode of 1. Lancet, 1960, ii, 693. 2. Judah, J. D. Nature, Lond. 1960, 185, 390. 3. Gallagher, C. H., Gupta, D. N., Judah, J. D., Rees, K. R. J. Path. Bact. 1956, 72, 193. 4. Dawkins, M. J. R., Judah, J. D., Rees, K. R. ibid. 1959, 77, 257. 5. Judah, J. D., Bjotvedt, G., Vainio, T. Nature, Lond. 1960, 187, 507.

mild

Otherwise, no granulocytopenia lasting two weeks. significant difference in the two groups could be detected. It is suggested that further investigation along these lines-by giving very large doses of a non-toxic antihistamine, should such a product become available-

might be valuable. The opinions expressed above do not necessarily reflect the views of the United States Navy Department. U.S. Naval Hospital, R. R COLLINS. C r collins. JOHN J R. Portsmouth, Virginia, U.S.A.

TEENAGE MORALS

SIR,-Dr. Judith Waterlow (July 8) is right to remind Dr. Comfort (June 17) that objective moral standards, which we are free to accept or reject, have always existed in Western civilisation. The idea of a relative and changing standard is an example of the brain-washing to which we are being subjected as a nation by materialistic forces. I was amazed by Dr. Comfort’s bland assumption that the standards inherent in Christianity and all the great religions cannot be lived and are irrelevant in present-day society. The new morality he advocates, including contraceptive instruction of youngsters of 15, is a return to the law of the jungle. Instead of a relaxation of standards mankind needs to grow up morally, in keeping with its intellectual and technical advances. The restoration of absolute moral standards is vital for the survival of civilisation. Bangor, G. G. Co. Down. G. G.

DALLAS.

CAROTID ARTERIES, BLOOD-PRESSURE, AND STROKES

SIR,-Dr. Lowe (July 8) raises doubts about the physiological significance of Dickinson and Thomson’s1 suggestion that reduced fluid-carrying capacity of the main vessels supplying the brain may play a dominant part in the haemodynamics of essential hypertension. In the normal animal

or

man, the resistance of any defined

part of the vascular bed is to be found almost wholly in the arterioles and capillaries, and the steady pressure gradient in any sizeable artery is very small indeed (e.g., as little as 0-03 mm. Hg per cm. in, the dog’s thoracic aorta,2 radius approx. 0-4 cm.). However, calculations on the data of Dickinson and Thomsongive results that do not accord with this. For example, in a normal subject, case 1, the combined resistance of the four arteries perfused was 0-016 mm. Hg per ml. bloodflow per min., while the total resistance of a normal cerebral vascular bed is 0-114. These calculations take into account the resistance of the cannulae used and assume a cerebral blood-flow of 750 ml. per min. and that the effective viscosity of blood in this situation is twice that of the perfusing fluid used by Dickinson and Thomson. These figures indicate that in life the mean pressure in the circle of Willis would have been 73 mm. Hg as against 85 in the aorta. A pressure drop of this size would be rather surprising. Furthermore, the same calculations using the same assumptions, when applied to a hypertensive subject (e.g., case 73), show that the arterial resistance would have been 54% of that in the whole cerebral circulation and this seems quite unreasonable. I know of no evidence to support the suggestion that the mean pressure in the circle of Willis in a person with hypertension may be as low as half that in the aorta and indeed the findings of Dr. Lowe indicate that this is not so. The conclusion must be that the conditions in those perfusion experiments differ markedly from those to be expected in vivo, and although they have revealed some difference between these arteries in normal and hypertensive subjects, the significance of this is uncertain. The 1. 2.

Dickinson, C. J., Thomson, A. D. Clin. Sci. 1960, 19, 513. McDonald, D. A., Taylor, M. G. Progress in Biophysics and Biophysical Chemistry (edited by J. A. V. Butler and B. Katz); vol. 9. London, 1959.

209 cause

tence

of these discrepancies might well be in the persisof postmortem spasm in the vessel wall, but other

explanations

are

possible.

Department of Physiology,

Medical College of St. Bartholomew’s Hospital, E.C.I. London, E.C.1.

BERGEL D. D BERGEL.

DRUG ADDICTION

SIR,-Dr. Chazan’s conclusion (July 1, p. 54) that " there may be more drug addicts than we think " cannot be sustained on the facts in her letter, because, according to accepted definitions, only the patient who was taking pethidine could be regarded as a drug addict. The other 8 patients seem to have been unstable personalities at odd times, resorted to amphetamines or barbiturates in excess and developed confusional mental states for which they In her penwere admitted to a psychiatric emergency unit. ultimate paragraph Dr. Chazan refers to the 8 patients as " spasmodic addicts " which surely excludes them from the category of true drug addicts. The following definition of drug addiction has been proposed 1:

who,

"

A state of periodic or chronic intoxication produced by repeated consumption of a drug and having the following characteristics: 1. An overpowering desire or need (compulsion) to continue taking the drug and obtain it by any means. 2. A tendency to increase the dose. 3. A psychic and physical dependence on the effects of the drug. 4. A detrimental effect on the individual and society."

In my

opinion this W.H.O. definition does not sufficiently emphasise the inevitability of abstinence symptoms on withdrawal of an addictive drug, which seems to me the only real distinction between addiction and habituation. My own definition is: " A physical and psychic dependence on a drug and the need to take it in progressively increasing doses or at shorter intervals because of the development of tolerance and because otherwise severe abstinence symptoms

experienced." Finally, I should like to point out that there is no register of drug addicts or obligation on doctors to report any patient requiring dangerous drugs. It so happens that departmental arrangements ensure that nearly all addicts are known to the

are

Home Office. London,

ELLIS STUNGO Honorary Secretary,

W.I.

Society

for the

Study

of Addiction.

ILEUS AND POSTOPERATIVE INTESTINAL MOTILITY

SIR,-Ishould like to congratulate Professor Wells and his workers (July 15) for their sound sense in presenting a preliminary communication of what is evidently going to be a major contribution. The reason why these flavours of the meal should be wafted to the jackals outside the kitchen is that the cooks might be saved some of the final preparation, which in this case they so obviously dread. That ileus is a curse of abdominal surgery no-one would but nowhere in this résumé do I see the admission that the cause of postoperative ileus is not the abdominal operation, but a fault in its conception, execution, or later management. Taking cholecystectomy as one of the examples of this study, it must be pointed out that ileus does not occur if the gallbladder is removed under the following conditions: (1) incision immediately over the organ; (2) seeing no other small intestine mixing-bowl " exploraexcept the duodenal corner; (3) no tion ; (4) no " traction " appendicectomy; (5) no excessive dissection of the porta hepatis; (6) no exposure of raw liver; (7) refusal to allow any bleeding at any time; (8) accurate suture of the fossa; (9) no drain except a T-tube if the common duct requires to be opened; (10) immediate ambulation; (11) limited fluid by mouth, and no solid food until flatus is

deny;

"

1. Tech.

Rep. Wld Hlth Org. 1957,

no. 116.

passed; (12) no other alimentation, either rectal or intravenous. I admit that ileus is a possibility if any of these conditions are forsworn, but this same attitude should apply to all abdominal surgery, and in it is contained the avoidance of ileus. I am not a bit surprised to hear that the stomach is the most sensible and static part of the intestine: we knew it already from the failure of immediate feeding which came into fashion some twenty-five years ago in reaction to the long starvation in vogue before. I agree with Professor Wells that the small intestine can absorb at an early hour after operation, and I find the long intubation useful after total gastrectomy; but it is hardly necessary after other operations. He could add that intravenous feeding is prejudicial to early jejunal function, by reversal of

the

absorption-gradient.

In work of this sort it is easier to criticise the preliminary communication than read the finished product. I want to save Professor Wells and his enthusiasts from being overstretched between balloon and bolus. OLIVER JELLY. Manchester. MEDICINE AND SOCIAL MEDICINE IN DEVELOPING COUNTRIES

SIR,-We should like to make some comments on your thoughtful and helpful annotation of July 1 on our report to the World Health Organisation on the teaching of social and preventive medicine at the King George’s Medical College, Lucknow. We agree that the department of social and preventive medicine should not permanently have responsibility for giving separate lectures on elementary psychology, but it is most important that someone should give them. The Ayurvedic College at Benares Hindu University is to be upgraded to provide a five-year M.B., B.s. course in allopathic medicine. The man chosen for this task, Dr. Udupa, is a former student of that college who has since taken his Canadian F.R.C.S., and the American F.A.c.s. He is, therefore, well able to assess the contribution which Ayurvedic medicine can make to " western " medicine. As the new college is a direct responsibility of the central Indian Government, and not the State Government, the pressure of numbers for admission can be resisted and it is the intention to limit new entries to 40 each year.

Our postgraduate students were not nominated by the medical services of the various States. They applied on their own initiative and a limited number were then accepted on the basis of academic attainment, experience, and aptitude for research work. We debated whether or not to discuss the organisation of rural health centres in our report, and how best to persuade doctors to work in them, and we decided that our primary responsibility was to train the future doctors for this work. We do, indeed, agree that the problem is an urgent one, and not only in India. Your comment on the age of marriage, with its reference to the legal minimum of 16 for females and 18 for males, is not quite correct. Under the Sarda Act (the Child Marriage Restraint Act), which came into effect in April, 1930, penalties are provided for the marriage of girls under 14 and of males under 18; but it will be a very long time before this Act is observed in rural India. Finally we appreciate your comment on the need for researches on how local social customs and organisation can be used to spread enlightened medicine without themselves

suffering. It is hoped to do this by giving the students simple research problems under supervision, by our arrangements for a one-month resident internship at the rural health centre, by a careful encouragement and selection of subjects for M.D. theses, and, above all, by close association with the other research departments in the University of Lucknow and especially those of anthropology and sociology. These schemes are already in operation, and a young anthropologist, Mr. K. A. Hasan, attached to the department of social and preventive